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The Value of the Time-Out

Sullivan, D Matthew MD

doi: 10.1097/01.EEM.0000340950.69012.8d
Letters

Charlotte, NC

Editor:

Dr. Edwin Leap and I should make a date to fly somewhere. I spend my free time immersed in aviation, and because of that, I've read many things focusing on two major topics: cool stuff and bad stuff. The more I fly and the more people I talk to who have gray hair, the more I realize that reading the bad stuff provides me with the motivation to become a better pilot and to never make the bad-stuff list. Having been in an airplane for 6000 hours with an instructor and almost bringing in a plane landing gear up, I'll share with you two of my favorite adages from flying that might be applicable to medicine.

There are two types of pilots: those who have landed gear up and those who will, and there are old pilots and bold pilots but never both.

I always use a checklist. I still make mistakes, but far fewer now that I programmed the checklist into my GPS, which I can't use until I complete the list. When Dr. Leap and I fly together, and as we approach the concrete at 100 miles an hour, I suspect he will quickly appreciate, in real terms, what the difference is between having no list, a paper list, an electronic list, and positive feedback with cockpit resource management (CRM).

There are some other cool concepts that cross from aviation to medicine, and they are lifesavers: have a sterile cockpit and authority control and use specific phraseology at specific times. We use some of these things in medicine, sometimes only when we feel like it.

While I actually liked Dr. Leap's funny article (“Time-Out: ‘Is This the Meteor That's Going to Kill You?’” EMN 2009;31[8]:6), I humbly share the following personal experiences from my recent medical practice.

In the midst of four ongoing traumas, Dr. X (a great colleague and trauma surgeon) was “teaching” one of our residents how to put a chest tube in as I walked by and stopped the procedure right before the blade touched the skin, calmly pointing to the radiology image on the screen: wrong side.

I called an “identifier time-out” (admittedly with an air of disdain because, after all, why do we have to do this?), and was quickly admonished by six staff members. I had personally carried the wrong bracelet in from the other room where another trauma was ongoing.

I went in to observe while one of our second-year residents was supervising an intern tapping the knee of a patient with gout, and they prepped the wrong knee. I asked the patient why he didn't say anything, and he said, “You are the doctor.”

Pairing these recent experiences with what I learned from reviewing records for the IHI patient safety initiative, I've come to realize that I have survived more by being lucky than good, certainly more than I once would have ever admitted.

While I appreciate Dr. Leap's humor, I'd submit that the more we try to do better, the more likely we actually will.

D. Matthew Sullivan, MD

Charlotte, NC

Dr. Leap responds: I agree. There are certainly things we can and should do to ensure the safety of our patients. I just have issues with the way some policies seem to add inefficiencies, slow us unnecessarily, and come from entirely nonmedical sources that have no knowledge of how we do our jobs.

As far as aviation, you're quite correct. I was an ANG flight surgeon for a number of years. Checklists were a big part of life, and I appreciated them every time I was in the air, especially when the Life Support guys were checking my parachute.

Nevertheless, no pilot is flying two aircraft at a time, but we are frequently managing many patients concurrently. Prolonged, detailed checklists are great in settings where we can move slowly and purposefully. In busier settings, I fear they simply add to what the Air Force calls task saturation, which degrades the ability to complete a given mission.

Still, I'm with you. Let's do whatever we can to be safe, but let's not do ridiculous things. I was recently told I couldn't have an anesthetic on the LP tray simultaneously with an open container of Betadine because I might confuse them. Really? When safety issues cross over into madness, I'm ejecting.

© 2009 Lippincott Williams & Wilkins, Inc.